Fillable City of Happy Valley Right of Way Usage (City of Happy Valley)

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City of Happy Valley Right of Way Usage (City of Happy Valley)

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BROWSE CITY OF HAPPY VALLEY (OR) FORMS

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City of Happy Valley
Right of Way Usage
License Application
Pursuant to Chapter 12.05 of the City of Happy Valley Municipal Code, except those utility
operators with a valid franchise agreement from the city, every person shall obtain a license
from the city prior to conducting any work in the rights-of-way.
Instructions: Please provide all information requested below, including applicable application fees, to City of
Happy Valley. The application must be signed by an authorized representative of the entity requesting a license.
The City will review the information and return an executed copy of the application, if approved. The copy of the
executed license application will serve as the license required by Chapter 12.05.
Contact Information/Additional Information/Instruction Directions:
Angela Tomasco, Senior Accountant, 503-783-3837, atomasco@happyvalleyor.gov
Applicant Information:
App
licant Name (Include Corporate Name registered with Oregon Secretary of State
and
any DBAs and affiliates that will construct, own or control any facilities in the
RO
W.)
Applicant’s Authorized Contact Name(s)
and Title(s):
Street City/State/Zip Phone
E-
mail Ad
dress Fax Number
Describe the Facilities to be Constructed or Operated:
General location of the existing and/or proposed
facilities:
Description of the approximate number of feet existing and/or to be installed in the ROW:
Describe whether the facilities are or will be aerial or
underground:
Describe the size of facilities and equipment that are or will be located
in, on, under, over, or
above the ROW:
Check all of the following that apply regarding the services to be provided by Applicant over the facilities in the ROW
(see definitions in Chapter 12.05 and provide a description of the utility services to be provided):
Cable Service
Communications Services
Natural Gas
Electricity
Water
Sanitary Sewer
Storm Sewer
Other: ________________________________________________________________________________________
Please provide a description of the utility services to be provided:
Attach documentation or a statement that demonstrates that the applicant has received or is legally qualified to receive
authorizations from state and/or federal authorities necessary to conduct the activities that will require use of the ROW.
Check box if no authorizations required
By:
Title
Date
The City of Happy Valley hereby grants to Licensee the License required pursuant to Chapter 12.05 of
the Municipal
Code:
By:
Title
Date
OFFICE USE ONLY:
Date License Issued Date License Expires Issued By
Mail
City of Happy Valley
16000 SE Misty Drive, OR, 97086 Attn:
Angela Tomasco, Senior Accountant
Fax
503-658-5236
Attn: Angela Tomasco
Senior Accountant
Email
Atomasco@happyvalleyor.gov
Submit your completed application packet by choosing one of the options below:
1
2
3
or
NOTE: Application must include
1. Certificate of insurance, or proof of self-insurance, in amounts defined by Happy
Valley Municipal Code 12.05.150
2. License application fee of $250.00
SIGNATURES:
By ex
ecuting this License, the undersigned affirms that he/she is an authorized representative of the
company (“Licensee”) with the authority to execute this License Application.
I hereby certify, on behalf of Licensee, that the information provided in the license application is
true and correct as of the date hereof, and that Licensee agrees to abide by the obligations set forth
in Chapter 12.05 of the City of Happy Valley Municipal Code.
Rev. 81519
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City of Happy Valley Right of Way Usage (City of Happy Valley)

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Completed 17 February 2021

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